Healthcare Provider Details

I. General information

NPI: 1396650248
Provider Name (Legal Business Name): ROOT HEALING SD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5434 OLIVE ST UNIT A
SAN DIEGO CA
92105-5054
US

IV. Provider business mailing address

5434 OLIVE ST UNIT A
SAN DIEGO CA
92105-5054
US

V. Phone/Fax

Practice location:
  • Phone: 619-840-9440
  • Fax:
Mailing address:
  • Phone: 619-840-9440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. MICHELLE JACKSON
Title or Position: OWNER
Credential: PMHNP-BC
Phone: 619-840-9440